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* 1. Facility Name:

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* 2. 6-digit CCN#

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* 3. First and Last Name:

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* 4. Email Address:

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* 5. On a scale from 1 (not effective) to 3 (very effective), how effective was the New Shift Root Cause Analysis (RCA) tool on helping your facility identify barriers to home therapy referrals and cause(s) of the disparity gap?

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* 6. On a scale from 1 (not effective) to 3 (very effective), please rate the effectiveness the MEI Dialysis Decision Aid had on engaging patients--eliciting patient values and opinions and beliefs about home therapies?

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* 7. On a scale from 1 (not effective or useful) to 3 (very effective or useful), how effective was the Deep Dive Disparity Report on helping you/your staff to understand the disparity gap and identify eligible patients of the disparate group in your facility?

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* 8. On a scale from 1 (not effective) to 3 (very effective), how effective was the Shift to Home podcast on encouraging your patients to seek more information on home therapies and/or dispel home therapy myths? (If N/A, select all N/A options that apply)

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* 9. On a scale from 1 (not effective) to 3 (very effective), how effective were the Sustainability Action Plan questions on helping your staff develop an actionable plan to sustain patient engagement, overall home therapy referrals, and disparity gap reduction?

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* 10. On a scale from 1 (not beneficial) to 3 (very beneficial), how beneficial was it to share and present on "best practices" during the #ENGAGE Campaign outcomes webinar? Example:  It was beneficial because I was able to establish new ways to promote home therapies based on what my peers presented during the #ENGAGE Campaign outcomes webinar.

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* 11. On a scale from 1 (not effective) to 3 (very effective), please rate the effectiveness the "Disparities in ESRD" webinar facilitated by Dr. Deidre Crews, had on improving you/your staff's understanding of health equity and disparities in ESRD.

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* 12. On a scale from 1 (not beneficial) to 3 (very beneficial), how beneficial were the monthly facility feedback reports in helping your facility identify areas for improvement and engage in rapid cycle improvement?

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* 13. On a scale from 1 (not useful) to 3 (very useful), please rate the usefulness the MATCH-D Tool had on helping staff identify eligible patients for home therapies.

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* 14. Rank the following interventions from 1 to 7  (1 being the most effective intervention; 7 being the least effective intervention) based on how effective they were to increasing home therapy consultations/referrals made throughout the New Shift initiative?

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* 15. How easy and convenient was it to complete and submit monthly home referral data via fax? Please note that patient-level data (PHI, PII) cannot be shared via email.

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* 16. Rank the following interventions from 1 to 7 (1 being the most effective intervention; 7 being the least effective intervention) based on how effective they were in helping to reduce the disparity gap in your facility ?

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* 17. Which of the following interventions will your facility continue to utilize to help promote home therapies and/or challenge disparities (Select all that apply):

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